Dear Editor,
As part of an article published in the IJPM, O'Donoghue etal. assessed patients’ attitudes to advance directives in Ireland (O'Donoghue etal. Reference O'Donoghue, Lyne, Hill, O'Rourke, Daly and Feeney2010). Two key findings were that there was a lack of knowledge among patients around the advance statement, but when introduced to the concept 84% of patients were interested in having the option of creating one.
As a trainee in South East Scotland I found that very few patients had an advance statement (equivalent to the advance directive in O'Donoghue's piece). Under Section 275 of the Mental Health (Care and Treatment) (Scotland) Act 2003, patients may create an advance statement when well to outline how they wish, and do not wish to be treated if they become unwell (Mental Health (Care and Treatment) Act Scotland, 2003). To find out why so few patients had an advance statement we undertook a survey of consultant attitudes to the advance statement, to see what barriers might prevent patients from using the advance statements.
Methods
We developed a brief six-question survey. This was distributed to general adult consultant psychiatrists within the Royal Edinburgh Hospital. Data were collected during Spring 2010. The questions were as follows:
1. Thinking back to your outpatient clinics over the period between 29/03/2010 and 11/04/2010, with how many patients did you discuss an advance statement?
2. Again, thinking back over your outpatient in the period between 29/03/2010 and 11/04/2010, how many, if any, patients did you direct to other services to discuss or consider an advance statement?
3. Thinking back over your outpatient clinics in the period between 29/03/2010 to 11/04/2010, what percentage of the patients that you've seen do you feel should have had an advance statement?
4. Thinking back over your outpatient clinics over the last 6 months, how often have you considered discussing advance statements with patients?
5. Who do you feel is the most appropriate person to discuss advance statements with your patient?
6. Finally, in an audit we found that a large number of patients held on a compulsory treatment order did NOT have an advanced statement. What barriers do you feel patients face in making an advanced statement?
Results
Out of 22 consultants contacted 12 responded to the survey. Only two consultants discussed an advance statement with one patient each in the 2-week period. Only two consultants referred a single patient each on to discuss the advance statement with another agency.
Seven responders rarely (less one discussion per month) considered discussing the advance statement, while four would occasionally discuss it (about one discussion with a patient about the advance statement per month). Nine consultants felt that the responsible medical officer or the community psychiatric nurse should be discussing the advance statement with the patient.
Four responders felt that no one should have an advanced statement, while two felt that all of their patients should. There were a range of reasons offered for patients not writing an advanced statement. Fear and denial about becoming unwell again was commonly cited. Some cited patients having a limited knowledge of the statement and of treatment options. Often patients requested that their doctor make the decision for them. A number of doctors were concerned about the amount of time that it would take the patient and themselves to write this statement. Some felt that it had so little power it wasn't worth the effort.
Discussion
While this is a very small survey, and was only carried out in one unit, it does offer us some points to consider. When a patient becomes unwell there is often a conflict between the ethical principals of autonomy and beneficence. We as doctors can see the mental illness and the suffering this brings and hope to treat this. In order to do this we may be obliged to detain an individual in hospital against their will. This impacts upon a patient's autonomy. The aim of the advance statement is to return some of that lost autonomy to the individual. Our study suggests that some doctors feel that this would be beneficial to the patient, and feel that it should be the patient's psychiatrist or community nurse who is helping them make this statement.
However, there are clearly a number of factors, which stand in the way of making these statements, including the usual suspects of time and knowledge. There is also a worrying lack of faith in the advance statement, that it is merely a paper exercise and has little real power in shaping a patient's care. In reality, this is not the case, with the obligation to pay attention to the advance statement being enshrined in law (Mental Health (Care and Treatment) Act Scotland, 2003).
As long as the attitude prevails that the advance statement has little value then little investment will be made in creating these documents. Simple practical measures such as providing patients with information leaflets about the statement may be enough to start all parties in the therapeutic alliance thinking about the document. The advance statement offers a golden opportunity to support patient autonomy at times when they are most vulnerable and to stand by one of the key principals of the act, that of participation.
